Information Collection

Claimant Statement About Loan of Food or Shelter

IC 43703 under ICR 200612-0960-006 · OMB 0960-0529.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0529 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-5062 Claimant Statement About Loan of Food or Shelter	Form
SSA-5062 Climant Statement About Loan of Food or Shelter Revised SSA-5062 Mock Up 090706.doc	Form
FACSIMILIE OF MSSICS HOUSEHOLD INCOME DATA SCREEN.doc MSSICS HOUSEHOLD INCOME DATA SCREEN	IC Document

IC Title:

Claimant Statement About Loan of Food or Shelter

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 416.1130-1148

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-5062	Climant Statement About Loan of Food or Shelter	Revised SSA-5062 Mock Up 090706.doc		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 65,540

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	65,540	-65,540	131,080
Annual IC Time Burden (Hours)	10,923	-10,923	21,846
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
MSSICS HOUSEHOLD INCOME DATA SCREEN	FACSIMILIE OF MSSICS HOUSEHOLD INCOME DATA SCREEN.doc	03/01/2007

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.